From the Department of Preventive Medicine and Public Health (Drs Bowen, Jacobs, and Fernandez), the Department of Psychiatry and Behavioral Medicine (Drs Jacobs), and the Behavioral Health Promotion Program (Dr Fernandez) at the Nova Southeastern University College of Osteopathic Medicine (NSU-COM) in Fort Lauderdale, Florida. Mr Gongidi and Mr Sierakowski are osteopathic medical students at NSU-COM.

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Context: An estimated 252,000 to 312,000 individuals have undiagnosed human immunodeficiency virus (HIV) infection in the United States. To date, little has been known about osteopathic physicians' attitudes and practices regarding routine HIV testing.

Methods: A cross-sectional survey of osteopathic physicians was conducted at the 106th Annual Convention of the Florida Osteopathic Medical Association in February 2009. Survey participants were asked 36 questions about osteopathic physician and patient sociodemographic factors and osteopathic physician attitudes and office practices regarding HIV testing and sexual history taking.

Results: A total of 233 osteopathic physicians completed the survey, but only 160 respondents (69%) met inclusion criteria of working in primary care and spending more than 50% of their time with patients. Almost two-thirds of participants were men, 80% were white, and the age range was 28 to 83 years. Twenty-two percent of participants recommended HIV testing at the initial patient visit, and 18% recommended annual HIV testing for all patients. Eighty-seven percent obtained a separate consent form for HIV testing, and 19% included HIV testing in general consent forms. About two-thirds of participants recommended annual HIV testing for homosexual men. Three factors were associated with recommending HIV testing at the initial patient visit: (1) recommending an annual HIV test for sexually active patients (odds ratio [OR], 12.82; 95% confidence interval [CI], 3.97-41.67); (2) having an agree/strongly agree attitude toward HIV testing (OR, 5.59; 95% CI, 1.63-19.23); and (3) obtaining a general consent form that included permission for HIV testing (OR, 3.25; 95% CI, 1.07-9.90).

Conclusion: Osteopathic physicians who practice primary care medicine can play a crucial role in reducing the number of individuals with undiagnosed HIV infection. More concerted efforts are needed to help osteopathic physicians incorporate HIV testing as part of routine care for all patients.

The United States Centers for Disease Control and Prevention (CDC) estimates that 1 million to 1.2 million people are living with human immunodeficiency virus (HIV) infection in the United States, and about one-quarter of these individuals are not aware of their infections.1-3 The CDC recently changed its estimates of the annual number of new HIV infections in the United States from 40,000 to more than 56,000.4 Moreover, the transmission rate among individuals who have undiagnosed HIV infection is estimated to be 3.5 times higher than among those who know of their serostatus.1,5

Because many individuals are diagnosed as having HIV infection late in the course of their disease, after development of symptoms, the CDC issued revised recommendations to promote routine HIV testing in healthcare settings.1,3 Some key changes made in CDC recommendations to promote widespread HIV screening are as follows: HIV screening for all patients between 13 and 64 years of age in all healthcare settings (after patients are notified that testing will be performed unless they decline, known as opt-out testing); annual HIV testing for individuals who engage in high-risk behaviors; and incorporation of permission for HIV testing into general consent forms (instead of using a separate consent form for HIV testing).6

Early diagnosis enables individuals to know their HIV status and to receive timely access to antiretroviral therapy, as well as access to preventive treatment for opportunistic infections. Such treatment can improve health and extend life.1,7,8 The high proportion of undiagnosed and late-diagnosed HIV infection supports the need for routine screening of HIV infection. In a 1999-2000 survey of more than 4100 US physicians by Bernstein et al,2 only 28% of respondents reported HIV screening of asymptomatic men or nonpregnant women. The data showed that women, African American, and Hispanic physicians were more likely than their counterparts to routinely screen patients for HIV infection.2 Physicians working in large cities were more likely than those in smaller cities or rural areas to conduct routine HIV screening.2 Furthermore, specialists in emergency medicine, internal medicine, and pediatrics were less likely than family/general practitioners to offer HIV screening.2

Despite the benefits of early diagnosis, a number of factors impede physicians from routinely screening for HIV infection in primary care settings. According to a comprehensive review conducted by Burke et al,9 physicians commonly cited the following barriers to HIV screening: insufficient time, burdensome consent processes, competing priorities, lack of knowledge and training, lack of patient acceptance, inadequate reimbursement, and pretest counseling requirements. In addition to these factors, Burke et al9 described other behavior-oriented barriers to routine HIV testing that had not previously been examined. For example, physicians' reluctant attitudes and practices regarding taking of sexual histories and routine vs targeted updates of patients' sexual histories may result in missed opportunities to provide prevention information, HIV diagnosis, or treatment for asymptomatic sexually transmitted infections (STIs). Similarly, the practice of routinely recommending HIV testing only to patients from “high-risk” groups may represent a missed opportunity of diagnosis for “low-risk” patients.

Furthermore, structural barriers in the form of state laws or statutes may impede implementation of routine HIV testing and incorporation of consent for testing into the general consent-for-care form. For example, Florida Statute 381.00410 requires patients to sign a separate written consent form for HIV testing—except for participants in anonymous epidemiologic surveys and for healthcare professionals who have had needlestick exposures to patients' body fluids.

For several decades, a large number of osteopathic physicians have been trained as primary care providers. Consequently, many osteopathic physicians play vital roles in all aspects of primary care medicine, including the treatment of patients with HIV infection or AIDS. Because of their important roles, osteopathic physicians are in position to promote early diagnosis of HIV infection. In order to assist osteopathic primary care physicians in routinely screening patients for HIV infection, it is essential to understand osteopathic physicians' attitudes, beliefs, and practices regarding routine HIV testing and the revised HIV screening recommendations from the CDC.1,3 To date, no such data are available.

In response to this need, we conducted a cross-sectional survey to understand osteopathic physicians' attitudes and practices toward HIV testing and sexual history taking. We also analyzed factors associated with osteopathic physicians' recommendations of HIV testing at the initial patient visit.

Methods

Participants

A total of 233 osteopathic physicians who attended the 106th Annual Convention of the Florida Osteopathic Medical Association (FOMA) between February 19, 2009, and February 22, 2009, completed an anonymous paper-and-pencil questionnaire. The Florida Osteopathic Medical Association is the third largest osteopathic medical association in the United States, with a membership of about 2000. Out of about 3500 active osteopathic physicians in the state of Florida, approximately 1000 registered to attend the convention.11

From the pool of completed surveys, we selected those respondents who met the following inclusion criteria: (1) specialized in family practice, internal medicine, emergency medicine, pediatrics, or obstetrics/gynecology and (2) spent more than 50% of their time in direct patient care. We chose these inclusion criteria because they mirrored those used in the most recent national survey of US physicians regarding screening, testing, and clinical practices for STIs, including HIV infection.12

Procedures

We recruited participants at the registration kiosk, and we made announcements at numerous sessions requesting participation in the study. Convention attendees were told that the survey was anonymous, with no personal identifiers. This information was also in the cover letter included with the survey packets, which were distributed at the registration kiosk, at the Nova Southeastern University College of Osteopathic Medicine (NSU-COM) alumni table, and in the rooms where the sessions were held.

Participants were instructed to complete the survey and return it to the research assistants. The survey required approximately 10 minutes to complete. Participants were informed that by completing the survey they were providing their consent to be part of the study. The Institutional Review Board at NSU approved the study in January 2009.

Survey Instrument

The survey instrument consisted of a series of items regarding physician practices that we adapted from a survey used by Kushner and Solorio,13 as well as questions that we developed regarding HIV testing and sexual history taking. We pilot-tested the instrument by administering it to a selected group of NSU-COM faculty osteopathic physicians. Based on their responses, we recast some of the items for clarity and reduced the number of items to ensure that it could be completed within 10 minutes. The final survey consisted of 36 questions divided into 3 broad areas: sociodemographic factors, physician practices, and physician attitudes. Descriptions of these areas follow:

Sociodemographic Factors—Participants reported their age, sex, ethnic background, setting of medical practice, approximate number of patients seen in a typical week, patient age groups, and patient racial/ethnic groups.

Physician Practices Regarding STI and HIV Testing and Sexual History Taking—Regarding their practices with new patients, participants reported if they obtained patients' general consent for treatment and if that consent included permission for HIV testing. Participants also reported whether they recommended HIV testing at the initial patient visit. In addition, participants noted the approximate amount of time spent with patients and their methods of taking patients' sexual histories.

For established patients, participants reported whether they recommended the following tests and vaccinations: annual HIV test for members of specific groups identified as being at high risk for HIV; HIV test for patients with new STI; hepatitis A and hepatitis B vaccinations; and human papillomavirus (HPV) vaccination for women. Participants also reported when they typically updated a patient's sexual history, whether they provided HIV testing in the office, and if they obtained separate consent for HIV testing.

Physician Attitude Scale—Using a 5-point Likert scale (1=strongly disagree to 5=strongly agree), participants reported how strongly they agreed or disagreed with five statements focused on sexual history taking and HIV testing practices. A sum score for each participant was calculated from responses to these statements; higher numbers meant a more positive attitude. Cronbach's α reliability coefficient for this physician attitude scale was 0.75. The statements used in the scale were as follows:

Doctors should routinely ask patients about alcohol and drug use as part of a routine visit.

Doctors should ask patients about sexual behavior as part of a routine visit.

If a patient is married, the doctor should not take a detailed sexual history.

Doctors should ask patients about intimate partner violence as part of a routine visit.

A sexual history should be part of a patient's initial visit.

Additional questions regarding physicians' recommendations for Papanicolaou (Pap) smears, further diagnostic testing, and other Likert-scale items were included in the survey. However, these items were not analyzed for the present study.

Data Analysis

Data were entered into a datafile (SPSS 16.0; SPSS Inc, Chicago, Illinois) and cross-checked for reliability using standard quality assurance procedures. We first con ducted descriptive analyses to describe the sample and to understand osteopathic physician practices. We then conducted bivariate analyses to examine theoretically relevant factors associated with recommending HIV testing at the initial patient visit. Factors that were found to be statistically significant (P≤.05) or that approached statistical significance at the univariate level were included in the multivariate logistic regression. Variables with low sample size (ie, <10) in any individual subgroup were not included in the final multivariate regression.

Results

Sample Characteristics

Of the 233 completed surveys, 160 met criteria for inclusion in data analysis. The characteristics of the 160 participating osteopathic primary care physicians and their clinical practices are summarized in Table 1. Almost two-thirds (105 [65.6%]) of participants were men, 128 (80%) participants were non-Hispanic whites, and the age range was 28 to 83 years. The majority (107 [66.9%]) of participants specialized in family practice.

Proportions of osteopathic primary care physicians in survey who answered yes to recommending sexually transmitted infection (STI) and human immunodeficiency virus (HIV) testing in various patient scenarios. Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item varied based on the number of participants who responded to that item.

Proportions of osteopathic primary care physicians in survey who answered yes to recommending sexually transmitted infection (STI) and human immunodeficiency virus (HIV) testing in various patient scenarios. Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item varied based on the number of participants who responded to that item.

Proportions of osteopathic primary care physicians in survey who answered yes to obtaining a general consent form or a separate consent form for human immunodeficiency virus (HIV) testing, and to carrying out specific HIV testing practices in their offices. Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item varied based on the number of participants who responded to that item. Abbreviation: ELISA, enzyme-linked immunosorbent assay.

Proportions of osteopathic primary care physicians in survey who answered yes to obtaining a general consent form or a separate consent form for human immunodeficiency virus (HIV) testing, and to carrying out specific HIV testing practices in their offices. Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item varied based on the number of participants who responded to that item. Abbreviation: ELISA, enzyme-linked immunosorbent assay.

Among participants who reported taking sexual histories of their patients, we found differences in the topics that the osteopathic physicians covered in their sexual histories (Figure 3). One hundred and thirty-four participants (83.8%) asked patients about marital status; 121 (75.6%), history of STIs; 121 (75.6%), contraceptive practices; 96 (60%), gender of sex partners; 87 (54.4%), sexual orientation; 85 (53.1%), number of sex partners; and 31 (19.4%), sexual satisfaction.

Figure 3.

Proportions of osteopathic primary care physicians in survey who answered yes to asking specific questions while taking a patient's sexual history. Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item varied based on the number of participants who responded to that item. Abbreviation: STI, sexually transmitted infection.

Proportions of osteopathic primary care physicians in survey who answered yes to asking specific questions while taking a patient's sexual history. Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item varied based on the number of participants who responded to that item. Abbreviation: STI, sexually transmitted infection.

Scenarios reported by osteopathic primary care physicians in survey for updating a patient's sexual history. Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item varied based on the number of participants who responded to that item.

Scenarios reported by osteopathic primary care physicians in survey for updating a patient's sexual history. Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item varied based on the number of participants who responded to that item.

We found statistically significant differences by sex in the proportion of osteopathic physicians who agreed with the statement “A sexual history should be part of a patient's initial visit” ( \({\chi}_{2}^{2}=6.49\) , P=.04). Among participants who were women, 55 (90.9%) either agreed or strongly agreed with this statement, compared to 104 participants (74%) who were men (Table 2). Women were also more likely than men to recommend annual STI screening for patients with histories of STIs (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.06-4.93) (Table 2).

We found that more time spent during a patient's initial office visit was positively associated with osteopathic physician's agreement with the statement “Doctors should routinely ask patients about sexual behavior as part of a routine visit” ( \({\chi}_{2}^{2}=11.96\) , P=.018). Forty-one osteopathic physicians (70.7%) who spent 30 minutes or more on the initial visit agreed or strongly agreed with this statement, as did 96 osteopathic physicians (47.9%) who spent 16 to 30 minutes on the initial visit and 22 osteopathic physicians (36.4%) who spent 15 minutes or less on the initial visit (Table 2).

*Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item are based on the number of participants who responded to that item

†Interdependence of these independent variables can be seen in the multivariate model in Table 4.

‡Some percentages do not total 100 because of rounding.

§Statistical significance defined as P≤.05.

∥Physician attitude toward HIV testing was determined by calculating a sum score for each participant from responses to the statements on the physician attitude scale; higher numbers meant a more positive attitude.

*Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item are based on the number of participants who responded to that item

†Interdependence of these independent variables can be seen in the multivariate model in Table 4.

‡Some percentages do not total 100 because of rounding.

§Statistical significance defined as P≤.05.

∥Physician attitude toward HIV testing was determined by calculating a sum score for each participant from responses to the statements on the physician attitude scale; higher numbers meant a more positive attitude.

†Physician attitude toward HIV testing was determined by calculating a sum score for each participant from responses to the statements on the physician attitude scale; higher numbers meant a more positive attitude.

†Physician attitude toward HIV testing was determined by calculating a sum score for each participant from responses to the statements on the physician attitude scale; higher numbers meant a more positive attitude.

Despite concerted efforts by the CDC and professional organizations to encourage primary care physicians to routinely recommend HIV testing to patients,1,6 only 22% of the participating osteopathic physicians in the present survey-based study recommended HIV testing at their patients' initial visits. This result is troubling given that CDC estimates indicate that between 252,000 and 312,000 individuals have undiagnosed HIV infection in the United States, and these individuals are 3.5 times more likely to transmit the virus to their partners than are individuals who know of their HIV infections.1,5 The present study identified three factors (ie, obtaining general consent that included permission for HIV testing, recommending annual HIV testing for sexually active patients, and positive attitudes toward HIV testing) that were significantly associated with recommendations for HIV testing at the initial patient visit.

Because primary care physicians are often a patient's main point of contact with the medical care delivery system, these physicians are in a unique position to identify undiagnosed HIV infection. Not only do they have the initial medical encounter with the patient who has undiagnosed HIV infection, but they might also be the only resource for HIV management for patients who are not interested in receiving HIV specialty care.14

The present study suggests that many osteopathic physicians are not following some CDC recommendations regarding HIV testing and that HIV testing has not yet become part of routine primary care. Perhaps some osteopathic physicians have not adopted HIV testing because they assume that their patients are not sexually active (eg, elderly patients), because their patients do not belong to high-risk groups (eg, injection drug users), or because seroprevalence of HIV in their geographic locations is less than 1 in 1000.1,6 However, evidence suggests that in such instances clinical judgments are correct only half the time.15 Not only does the unreliability of such clinical judgments increase the salience of routinely offering HIV testing to all patients, but it also highlights the importance of regularly taking sexual histories regardless of patient characteristics.

Approximately 87% of osteopathic physicians surveyed in the present study obtained a separate consent form for HIV testing, while only 19% obtained a general consent form that included permission for HIV testing. It is probable that the Florida statute10 requiring separate consent for HIV testing is the reason for this finding.

Similar to conclusions reported by Bernstein et al,2 we found that osteopathic physicians who were women, black, or Hispanic were more likely to screen patients for HIV than were other osteopathic physicians. In addition, osteopathic physicians who were women were more likely than osteopathic physicians who were men to recommend annual HIV testing for patients with new STIs, and women showed greater agreement than men with the statement “A sexual history should be part of a patient's initial visit.”

Because HIV testing has not yet become a routine part of primary care, many individuals with undiagnosed HIV infection have multiple contacts with the healthcare system before their HIV is detected. For example, Liddicoat et al16 showed that it took five visits, on average, by the patient to the same institution before a diagnosis of HIV infection was made. In another study, 58% of individuals who enrolled in a new program for routine HIV screening had never before been offered HIV testing.17 In a study that examined risk-based HIV testing vs universal HIV testing, risk-based approaches (eg, based on clinical indicators or previous STI) did not yield earlier diagnosis of HIV infection than universal testing.18 Not routinely offering HIV testing in primary care settings is a “missed opportunity”—not only for early diagnosis and treatment but also for prevention of future infections.

Although the large number of individuals with undiagnosed HIV infection and the increased likelihood that these individuals unwittingly transmit HIV infection12 provide sufficient impetus for osteopathic physicians to adopt routine HIV screening, many osteopathic physicians may perceive state and local laws and liability considerations as barriers to widespread adoption of CDC recommendations. Mahajan et al19 reported that 34 states and the District of Columbia have statutory frameworks that are consistent with or neutral toward adopting the testing components addressed by the CDC recommendations. Although Florida has a statute that requires a separate consent form for HIV testing,10 that statute does not require pretest counseling.19 Efforts to educate osteopathic physicians regarding statutory issues and the legal implications of those issues are necessary.

Although our findings are based on a convenience sample of osteopathic primary care physicians attending the annual FOMA convention and, therefore, are not representative of the osteopathic medical profession as a whole, many of the characteristics of our survey participants are similar to those reported in other national studies.20 In order to maximize participation, we limited the number of items in our survey. Therefore, there may be important information that we did not assess. Similarly, the number of independent variables that we examined was limited by the number of questions that we asked. Nonetheless, the present study offers some insight into behaviors and attitudes of Florida osteopathic physicians towards HIV testing and sexual history taking.

Conclusions

Although most osteopathic physicians recommend annual HIV testing for patients in high-risk groups (eg, men who have sexual intercourse with other men, injection drug users), more concerted efforts are needed to help osteopathic physicians incorporate HIV testing as part of routine care for all of their patients. Osteopathic physicians can play a crucial role in reducing the numbers of individuals with undiagnosed HIV infection and in helping to ensure that individuals who are diagnosed with HIV infection receive proper treatment. Further research is needed on potential changes in osteopathic medical education to improve osteopathic physicians' understanding of HIV screening practices and to encourage more favorable medical and legal perspectives among osteopathic physicians regarding routine HIV screening.

Copies of the survey questionnaire are available from Dr Fernandez upon request.

Financial Disclosures: Student Doctor Gongidi received funding for this study through an NSU-COM research fellowship. Student Doctor Sierakowski and Drs Bowen, Jacobs, and Fernandez have no relevant financial relationships to disclose. All authors have no relevant conflicts of interest to disclose.

We would like to thank NSU-COM Dean Anthony J. Silvagni, DO, PharmD, for his continued support of the research fellowship. We would also like to thank Robert T. Hasty, DO, and Nilda Hernandez, AA, at NSU-COM. We are indebted to Michelle Winn, CMP, at the Florida Osteopathic Medical Association (FOMA) for her assistance in coordinating the study during the FOMA convention. Most important, we appreciate the participation of all the osteopathic physicians who took the time to complete our survey.

Proportions of osteopathic primary care physicians in survey who answered yes to recommending sexually transmitted infection (STI) and human immunodeficiency virus (HIV) testing in various patient scenarios. Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item varied based on the number of participants who responded to that item.

Proportions of osteopathic primary care physicians in survey who answered yes to recommending sexually transmitted infection (STI) and human immunodeficiency virus (HIV) testing in various patient scenarios. Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item varied based on the number of participants who responded to that item.

Proportions of osteopathic primary care physicians in survey who answered yes to obtaining a general consent form or a separate consent form for human immunodeficiency virus (HIV) testing, and to carrying out specific HIV testing practices in their offices. Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item varied based on the number of participants who responded to that item. Abbreviation: ELISA, enzyme-linked immunosorbent assay.

Proportions of osteopathic primary care physicians in survey who answered yes to obtaining a general consent form or a separate consent form for human immunodeficiency virus (HIV) testing, and to carrying out specific HIV testing practices in their offices. Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item varied based on the number of participants who responded to that item. Abbreviation: ELISA, enzyme-linked immunosorbent assay.

Proportions of osteopathic primary care physicians in survey who answered yes to asking specific questions while taking a patient's sexual history. Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item varied based on the number of participants who responded to that item. Abbreviation: STI, sexually transmitted infection.

Proportions of osteopathic primary care physicians in survey who answered yes to asking specific questions while taking a patient's sexual history. Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item varied based on the number of participants who responded to that item. Abbreviation: STI, sexually transmitted infection.

Scenarios reported by osteopathic primary care physicians in survey for updating a patient's sexual history. Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item varied based on the number of participants who responded to that item.

Scenarios reported by osteopathic primary care physicians in survey for updating a patient's sexual history. Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item varied based on the number of participants who responded to that item.

*Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item are based on the number of participants who responded to that item

†Interdependence of these independent variables can be seen in the multivariate model in Table 4.

‡Some percentages do not total 100 because of rounding.

§Statistical significance defined as P≤.05.

∥Physician attitude toward HIV testing was determined by calculating a sum score for each participant from responses to the statements on the physician attitude scale; higher numbers meant a more positive attitude.

*Although a total of 160 survey respondents met inclusion criteria, sample sizes for each survey item are based on the number of participants who responded to that item

†Interdependence of these independent variables can be seen in the multivariate model in Table 4.

‡Some percentages do not total 100 because of rounding.

§Statistical significance defined as P≤.05.

∥Physician attitude toward HIV testing was determined by calculating a sum score for each participant from responses to the statements on the physician attitude scale; higher numbers meant a more positive attitude.

†Physician attitude toward HIV testing was determined by calculating a sum score for each participant from responses to the statements on the physician attitude scale; higher numbers meant a more positive attitude.

†Physician attitude toward HIV testing was determined by calculating a sum score for each participant from responses to the statements on the physician attitude scale; higher numbers meant a more positive attitude.